The Efficacy and Safety of Eravacycline in the Management of Infections: A Single-Center Experience

Background/Objectives: Eravacycline is a fluorocycline antibiotic increasingly used for drug-resistant or difficult-to-treat infections, including off-label indications, with limited real-world clinical data. This study aimed to characterize the effectiveness, safety, and overall risk-benefit profile of eravacycline using an adapted Desirability of Outcome Ranking (DOOR) framework. Methods: We conducted a retrospective, single-center observational study of adult patients who received ≥48 h of eravacycline at an academic medical center between May 2022 and October 2023. Clinical response was assessed at the end of therapy, alongside 30-day all-cause mortality. Treatment-emergent adverse events (TEAEs) were recorded and normalized per 100 eravacycline-days. An adapted DOOR framework integrated efficacy, toxicity and mortality into an ordinal composite outcome, with analyses stratified by pathogen and site of infection. Results: A total of 140 patients contributed 151 eravacycline courses. Intra-abdominal (41.7%) and lower respiratory tract infections (27.8%) were the most common indications. Treatment success was observed in 69.5% of courses, while 30-day all-cause mortality was 23.6%. TEAEs occurred in 52.3% of courses and frequently led to eravacycline discontinuation. Exposure-normalized TEAE rates were highest in shorter courses, with gastrointestinal intolerance predominating early, while hepatoxicity and coagulation abnormalities were more frequent with intermediate treatment durations. DOOR analysis demonstrated highly desirable outcomes in 48.3% of courses, with more favorable profiles observed in carbapenem-resistant Enterobacterales (CRE), vancomycin-resistant Enterococci (VRE) and nontuberculous mycobacteria (NTM) infections. Bloodstream infections were associated with less desirable outcomes. Conclusions: Eravacycline demonstrated meaningful real-world activity across complex infections but was limited by frequent toxicity. The DOOR framework provided a patient-centered context for organism- and site-specific risk-benefit assessment.